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2. Name*
4. Date of Test*
   Date of Test
5. Brand of Test*
7. Date of Symptoms (if applicable)
   Date of Symptoms (if applicable)
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
17. Email Address*
19. Date of Birth*
    Date of Birth
20. Sex at Birth*
    -- Select One --MaleFemale
22. Employer or School (if a child)
24. Vaccination Status*

    1. unvaccinated
    2. one dose
    3. two doses
    4. three doses
    5. more than three doses

26. Note:  We are no longer investigating every case.  Because of this, you may not receive a phone call from our office.  Refer to "What to do if you test positive with an over-the-counter (OTC) test kit" link at sjccovid.com

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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field